A nurse in an acute mental health center is performing a physical assessment on a client. Which of the following findings should the nurse document under the integumentary system? (Select all that apply.)

Numbness

Skeletal deformities

Alopecia

Ecchymosis

Answer and Explanation

The Correct Answer is A

A. Transference: Transference occurs when a client projects feelings about someone from their past onto the therapist or nurse. The client’s feelings about the nurse being similar to their mother fit this description.
B. Confrontation: Confrontation involves addressing discrepancies or issues directly, which is not the focus here. The situation described is about the client’s feelings towards the nurse.
C. Countertransference: Countertransference occurs when a nurse or therapist has emotional reactions based on their own past experiences, not the client’s feelings about the nurse.
D. Incongruence: Incongruence refers to a mismatch between a person's experiences and their self-concept. The situation described involves the client's feelings toward the nurse rather than incongruence.

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Correct Answer is C

Explanation

A. "You are in really good shape for your age." This response minimizes the client’s feelings and focuses on physical condition rather than addressing the emotional and existential concerns expressed by the client.
B. "This is just a minor setback. You will be back on your feet in no time." This response downplays the significance of the client’s feelings and may be perceived as dismissive. It does not address the client’s concerns about the end of life.
C. "You feel as though your life is ending?" This response acknowledges and validates the client’s feelings, providing an opportunity for further exploration and support. It shows empathy and encourages the client to express their emotions.
D. "The doctors are going to take good care of you. There is nothing to worry about." This response reassures the client about medical care but does not address the emotional aspect of the client’s statement regarding the end of life.

A. Express sympathy for the client during interaction. B. Assist the client in decision-making by giving sound advice. C. Tell the client that he should make direct eye contact when communicating verbally. D. Watch the client for nonverbal cues.

Correct Answer is D

Explanation

A. Express sympathy for the client during interaction: Sympathy can create a sense of pity and isn't as effective as empathy, which fosters understanding.
B. Assist the client in decision-making by giving sound advice: Giving advice can undermine the client's autonomy and may not be suitable in therapeutic communication.
C. Tell the client that he should make direct eye contact when communicating verbally: Forcing direct eye contact can be intimidating for someone who is depressed.
D. Watch the client for nonverbal cues: Observing nonverbal cues can provide valuable information about the client's emotional state and needs.

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A nurse in an acute mental health center is performing a physical assessment on a client. Which of the following findings should the nurse document under the integumentary system? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

Explanation

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